Single-stage flexor tendon transfer for the treatment of severe concomitant peroneus longus and brevis tendon tears

Preoperative Gait Analysis of Peroneal Tendon Tears

BACKGROUND

Little is known regarding the impact of peroneal tendon tears on function. This study quantifies gait changes associated with operatively-confirmed peroneal tendon tears.

METHODS

Sixty-five patients with unilateral peroneal tendon tears were prospectively evaluated using preoperative 3D multisegment gait analysis of both limbs. Data were analyzed according to pattern/severity of tears, as confirmed surgically: peroneus brevis tears, reparable (PBR); peroneus brevis tears, irreparable (PBI); peroneus longus tears, irreparable (PLI); and concomitant irreparable tears of both tendons (PBI+PLI). The following parameters were analyzed: ankle sagittal motion, coronal motion, axial rotation, foot progression angle, sagittal power, sagittal moment.

RESULTS

Twelve patients (18.5%) had the PBR pattern, 37 (56.9%) PBI, 10 (15.4%) PLI, and 6 (9.2%) PBI+PLI. Compared with the contralateral, nonpathologic extremities, limbs with peroneal tears had diminished ankle sagittal motion (mean 23.14 vs 24.30 degrees, P = .012), ankle/hindfoot axial rotation (6.26 vs 7.23 degrees, P = .001), sagittal moment (1.16 vs 1.29 Nm/kg, P < .001), and sagittal power (1.24 vs 1.47 W/kg, P < .001). The most severe tear patterns had the greatest derangements in multiple parameters of gait (PBI+PLI > PBI or PLI > PBR). For example, all groups except PBR had loss of ankle sagittal moment and/or power in the affected limb, and the greatest losses in moment and power were in the PBI+PLI group (1.22 vs 0.91 Nm/kg, P = .003 for moment; 0.73 vs 1.31 W/kg, P < .001 for power). The PBI+PLI group had a >10-degree varus shift in coronal motion on the affected side (P = .002).

CONCLUSION

This is the first study to demonstrate diminished biomechanical function in patients with peroneal tendon tears. In vivo 3-dimensional gait analysis found significant changes in hindfoot motion, ankle motion, and ankle power. Impairments were related to the pattern and severity of the tears, and demonstrated a strong association of peroneal tendon tears with diminished ankle plantarflexion strength.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Intraosseous Anchorage of a Collagen Matrix Graft to Enhance Repair of Peroneus Brevis Tendon Degeneration

INTRODUCTION

Chronic degeneration of the peroneus brevis tendon (PBT) at its insertion to the base of the fifth metatarsal is uncommon; however, when present it can be a challenge to treat. Repair of the PBT often requires tubularization with or without a peroneus longus tendon transfer. These repairs, however, may not provide resultant full muscle strength, especially if ostectomy of the fifth metatarsal base is required. We report outcomes following a novel technique for anatomic repair of degenerative PBT with intraosseous fifth metatarsal base fixation of a collagen matrix graft.

METHODS

Thirteen consecutive patients (14 procedures) with degeneration of PBT that underwent tendon repair augmented with collagen matrix graft from 2011 to 2019 were reviewed retrospectively. We present outcome data of these 13 patients that were followed for at least 12 months.

RESULTS

Muscle strength, complications, and patient-reported subjective outcomes were reported. There were 10 females and 3 males. Average age was 49.1 years, and average follow-up was 34.9 months. Muscle strength was reported at 5/5 to the PBT by the final follow-up for 92% of patients. There were minimal complications, 84.6% (11/13) of patients had no limitation in activity level, and 92% (12/13) would recommend this procedure to a friend.

CONCLUSION

Outcomes for this novel repair technique for insertional degenerative PBT have never been reported before and show excellent results with long-term follow-up.

Peroneus brevis tendon injuries: Report of two cases and review of literature

The incidence of peroneal tendon disorders in the population is unknown and they are usually overlooked. We report two cases of peroneus brevis injuries and a comprehensive literature review was performed. The first case was a 53-year-old man presented with persistent pain on the lateral aspect on the left ankle during the last four years and difficulty to bear weight during the last year. MRI showed longitudinal tear of peroneus brevis tendon and the patient underwent surgical treatment. The second case was a 46-year-old woman with persistent pain on the lateral aspect of the ankle with a history of a road traffic accident two years ago. Although MRI showed a peroneus brevis tendon tear, this was a false positive finding. Surgical treatment revealed no tear and symphysiolysis managed to relieve patient's symptoms. Even though MRI is the most effective diagnostic tool in depicting peroneal tendon injuries, there are false positive findings. In cases when symptoms persist, surgical exploration is indicated.

Clinical Outcomes of Peroneal Tendon Tears: A Systematic Review

The purpose of this study was to provide an overview of the available evidence on peroneal tendon tears and the outcomes after surgical intervention. A systematic review of the literature was performed using MEDLINE, Embase, and Cochrane. Criteria for inclusion were clinical studies reporting outcomes after treatment for peroneal tendon tear within the last 10 years. Nine studies evaluating 336 patients (146 males/190 females) and 336 ankles were included in this review. The mean age of included patients was 46.3 years (range, 46-56.9 years). The weighted mean follow-up was 23.82 months (range 9.2-78 months. Five surgical interventions were reported: primary repair with tenodesis, primary repair without tenodesis, FDL tendon transfer, FHL tendon transfer, and allograft reconstruction. Four studies recorded the AOFAS score, with a weighted mean preoperative score of 69.58 and a weighted mean postoperative score of 88.82. Six studies measured the VAS score showing an improvement from a mean weighted preoperative score of 4.68 to a mean weighted postoperative score of 1.2. FAAM score was measured in 3 studies, which showed an improvement from 41.1 preoperatively to 84.4 postoperatively. The average overall complication rate was 38.7% (130/336) with the most commonly reported minor complication being ankle pain, which made up 46.2% of all minor complications (56/121). Primary repair without tenodesis was associated with a higher complication rate compared to any other surgical intervention (p=.001176). The current systematic review showed that overall clinical outcomes were positive in lieu of the different modalities of surgical intervention for peroneal tendon tears.

Transfer of the Posterior Tibial Tendon for Chronic Peroneal Nerve Palsy

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The common peroneal nerve (CPN) is one of the most frequently injured nerves of the lower extremity.

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One-third of patients who develop CPN palsy proceed to chronic impairment without signs of recovery.

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Ankle-foot orthoses can provide improvement with respect to gait dysfunction and are useful as a nonsurgical treatment option.

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Severe cases of CPN palsy demonstrating no signs of recovery may require operative intervention with tendon transfer.

Tendon Transfers and Their Role in Cavus Foot Deformity

Management of the cavus foot is a difficult task for the foot and ankle surgeon. Tendon transfers have been a longstanding accepted treatment for the flexible cavus foot. Performing tendon transfers requires an in-depth understanding of the patient's medical history, factors leading to the development of deformity, as well as the deforming forces contributing to the deformity. Evaluation of the patient for rigid, progressive, and/or spastic deformities is critical to avoid postoperative complications. Educating the patient on postoperative rehabilitation, potential complications, and postoperative expectations is essential to ensure appropriate surgical outcomes.

Reconstruction of Concomitant Ruptures of Peroneus Longus and Brevis Tendons: A Case Report and Literature Review

Peroneal tendon ruptures are caused by inversion trauma of the ankle and are often mistaken for simple ankle sprains. As a result, peroneal tendon ruptures are underdiagnosed; especially a concomitant rupture of both the brevis and longus tendons is extremely rare. We describe the case of concomitant rupture of both peroneal tendons in a 50-year-old male, diagnosed with magnetic resonance imaging and treated with a flexor digitorum longus tendon transfer. The flexor digitorum longus tendon was mobilized, transferred laterally, and anchored to the distal and proximal stubs of the peroneal tendons, acting like a bridge. At final follow-up (19 months after index surgery), the patient was relieved from his symptoms and had full range of motion. Imaging demonstrated a durable reconstruction. Evidence for the preferred surgical treatment is lacking in the current literature and is limited to small case series and case reports. Randomized prospective studies should be conducted to determine the optimal treatment. Based on current available data, surgical technique should be based on clinical observation (e.g., tendon quality) and imaging findings.

Clinical and Functional Outcomes of Peroneus Longus to Brevis Tendon Transfer

BACKGROUND

Peroneal tendon lesions can cause debilitating pain, but operative treatment remains controversial. Some studies recommend peroneal tenodesis or transfer if more than half of the tendon is affected. However, clinical outcomes and inversion/eversion motion after peroneal transfer have not been investigated yet.

METHODS

Patients who underwent distal peroneus longus to brevis transfer for major peroneus brevis tendon tears with a minimum follow-up of 2 years were included. Clinical outcome parameters included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, the German Foot Function Index (FFI-D), and Karlsson-Peterson score. Functional outcome was tested with a standardized active range-of-motion (ROM) and isokinetic strength measurement protocol, including concentric and eccentric eversion and inversion tests.

RESULTS

Of total 23 eligible patients, 14 (61%) were available for follow-up. Clinical outcome scores were good with AOFAS 86 ± 16 points, FFI-D pain 26% and FFI-D disability 26%, and Karlsson-Peterson score 78 ± 23 points. There was no difference in strength in comparison to the contralateral foot (all P > .05). Isokinetic strength was 16.3 ± 4.9 Nm (108% of contralateral side) and 18.8 ± 4.5 Nm (101%) at concentric 30 deg/s and eccentric 30 deg/s eversion tests, as well as 15.7 ± 5.2 Nm (102%) and 18.7 ± 3.3 Nm (103%) at concentric 30 deg/s and eccentric 30 deg/s inversion tests, respectively. There was no difference in ROM compared to the contralateral side (eversion/inversion 14.5-0-18.7 vs 14.1-0-16.1 degrees).

CONCLUSION

Peroneus longus to brevis transfer is a viable option for treating severe peroneus brevis tendon tears and does not compromise measurable strength or ROM in inversion or eversion in comparison to the contralateral ankle joint.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Diagnosis and Operative Treatment of Peroneal Tendon Tears

Peroneal tendon tears are a common but under-recognized source of ankle pain and dysfunction. Recognition of the characteristic symptoms, physical findings, and imaging results of peroneal tendon tears is essential for accurate diagnosis and appropriate treatment. Acute, limited tears of a single peroneal tendon may be debrided and repaired. However, by the time operative treatment is undertaken, many tears of a single tendon are sufficiently advanced that the surgeon may need to consider excision of the nonviable segment and tenodesis of the damged tendon to the to the adjacent peroneal tendon. Irreparable tearing of both peroneal tendons may be treated with flexor tendon transfer and/or allograft reconstruction. This review article focuses on diagnosis and operative treatment of peroneal tendon tears, including the treatment algorithms, operative technique, and published outcomes.

Diagnosis and Operative Treatment of Peroneal Tendon Tears

Peroneal tendon tears are a common but under-recognized source of ankle pain and dysfunction. Recognition of the characteristic symptoms, physical findings, and imaging results of peroneal tendon tears is essential for accurate diagnosis and appropriate treatment. Acute, limited tears of a single peroneal tendon may be debrided and repaired. However, by the time operative treatment is undertaken, many tears of a single tendon are sufficiently advanced that the surgeon may need to consider excision of the nonviable segment and tenodesis of the damged tendon to the to the adjacent peroneal tendon. Irreparable tearing of both peroneal tendons may be treated with flexor tendon transfer and/or allograft reconstruction. This review article focuses on diagnosis and operative treatment of peroneal tendon tears, including the treatment algorithms, operative technique, and published outcomes.

Minimally Invasive Retrograde Method of Harvesting the Flexor Hallucis Longus Tendon: A Cadaveric Study

BACKGROUND

Use of the flexor hallucis longus (FHL) tendon is well described for several tendon augmentation procedures. Harvesting the FHL through an open medial approach is commonly done, but is associated with anatomic risks. Recently, several authors have described a minimally invasive (MI) technique to harvest the FHL tendon utilizing a hamstring tendon stripper commonly used in ACL reconstruction. The purpose of this study was to evaluate the safety and effectiveness of harvesting the FHL tendon using this novel minimally invasive retrograde approach.

METHODS

The FHL tendon was harvested through a transverse plantar incision over the interphalangeal joint of the great toe in 10 fresh-frozen cadaver lower extremities. A lateral-based incision for peroneal tendon repair was made and the FHL was retrieved. Tendon length, complications, and interconnections between the FHL and flexor digitorum longus (FDL) were recorded and classified. The specimens were then dissected by a single surgeon in a standardized fashion, and damage to any surrounding structures was recorded.

RESULTS

The average length of the FHL tendon from the distal stump to the first intertendinous connection was 13.3 cm (range 8.8-16 cm, SD 2.3 cm). Eight cadavers demonstrated Plaass type 1 interconnections whereas 2 demonstrated type 3. There was no injury to the medial and lateral plantar arteries and nerves, plantar plate, or FDL tendons. One FHL tendon was amputated at the level of the sustentaculum during graft harvest. No injury of the medial neurovascular structures occurred with retrieval of the FHL tendon through the lateral incision.

CONCLUSIONS

We found that care must be taken when approaching the sustentaculum with the tendon harvester in order to avoid amputation of the graft against a hard bony endpoint. Additionally, flexion and extension of the lesser toes could aid in successful tendon harvest when tendon interconnections were encountered.

CLINICAL RELEVANCE

Using this MI technique appears to be a safe and effective way to obtain a long FHL tendon graft for tissue augmentation.

Lateral Transfer of the Flexor Digitorum Longus for Peroneal Tendinopathy

BACKGROUND

Few studies have reported midterm outcomes after single-stage flexor digitorum longus (FDL) tendon transfer to the lateral foot for irreparable rupture of the peroneal tendons.

METHODS

Over a 7-year period (2008-2015), 25 consecutive patients underwent transfer of the FDL to the fifth metatarsal for irreparable peroneal tendon tears. Of these, 15 patients were available for inclusion with a mean follow-up of 53.7 ± 23.3 months, mean age at surgery of 48.4 years, and mean body mass index (BMI) of 29.8 kg/m². Patients completed the pain visual analog scale (VAS), Foot Function Index (FFI), Short Musculoskeletal Function Assessment (SMFA), and Foot and Ankle Ability Measure (FAAM) and participated in range of motion, peak force, and peak power testing.

RESULTS

All 15 patients were satisfied with their surgery and reported a reduction in their pain level with a decreased VAS of 5.6 ± 2.5. The mean FFI was 12.8 ± 9.2, the SMFA Function Index was 12.4 ± 8, and the mean SMFA Bothersome Index was 11.5 ± 11. The mean FAAM was 86.4 ± 9.7. Patients had on average 58% less eversion and 28% less inversion compared with the nonoperative side. Isometric peak torque and isotonic peak velocity were 38.4% and 28.8% less compared with the contralateral side, respectively. The average power in the operative limb was diminished by 56% compared with the nonoperative limb.

CONCLUSION

In this small case series with midterm follow-up, FDL transfer to the lateral foot for significant, irreparable peroneal tendinopathy was an effective and durable treatment option.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Peroneal Tendon Tears: We Should Consider Looking at the Muscle Instead

INTRODUCTION

The purpose of this study was to determine whether tears of the peroneus brevis (PB) tendon correlate with increased fatty infiltration of the PB muscle on MRI compared with musculature without clinical evidence of peroneal pathology.

METHODS

Ankle MRI scans of patients with PB tendon tearing (tear group) were compared with those of patients without clinical evidence of peroneal pathology (control group). Two reviewers graded the PB muscle belly according to the Goutallier classification.

RESULTS

Thirty patients were included in each group. The mean Goutallier scores for the tear and control groups were 0.52 (±0.72) and 0.05 (±0.15), respectively (P = 0.0019). The level of interobserver agreement between reviewers was moderate (intraclass correlation coefficient = 0.75; 95% confidence interval, 0.57 to 0.85).

DISCUSSION

Patients with PB tendon tear demonstrate markedly higher grades of fatty degeneration compared with patients without peroneal pathology. The Goutallier classification may become a valuable instrument for assessing the severity of a PB tear.

LEVEL OF EVIDENCE

Level III-diagnostic study.

Postoperative Imaging of the Ankle

OBJECTIVE

The purpose of this article is to review imaging after commonly encountered surgical interventions of the ligaments, tendons, and soft tissues around the ankle. Intraoperative images, when available, are provided to improve conceptual understanding of these complex procedures.

CONCLUSION

Surgical interventions in the ankle are becoming more prevalent with increasing athletic demands and emerging focus on techniques for prevention of joint injury. Knowledge of the surgical techniques, imaging appearances, and complications in the postoperative ankle is necessary for the accurate diagnosis of postoperative complications and for optimal patient care.

Clinical results of peroneal tendon repair in a retrospective series of 30 patients

INTRODUCTION

Peroneal tendinopathy is an under-diagnosed pathology, mainly triggered by ankle sprain. Failure of medical treatment often leads to surgery, with modalities adapted to the lesion type. The present study aimed to assess clinical and functional results of tendon repair and to analyze the influence of hindfoot alignment on quality of outcome. The study hypothesis was that hindfoot varus impairs medium-term results.

MATERIALS AND METHODS

A retrospective series of 30 patients undergoing peroneal tendon repair or tenodesis was analyzed at a mean 20 months' follow-up. All patients had preoperative ultrasound scan or NMRI. Clinical assessment was based on AOFAS and FAAM scores. Hindfoot alignment was assessed on Méary view; 2 groups were distinguished: valgus (n=11) and varus (n=17).

RESULTS

Mean AOFAS score improved, from 74.5±11.2 preoperatively to 86.7±9.4 at follow-up. There was a significant intergroup difference (p=0.0003) in AOFAS at follow-up: valgus, 93/100; varus, 82/100. There was no significant intergroup difference in FAAM score. Time to surgery, lesion type and surgical technique did not influence clinical results.

DISCUSSION/CONCLUSION

Clinical results for surgical repair of peroneal tendons were satisfactory and in line with literature reports. However, hindfoot varus was associated with poorer results, raising the possibility of correction by opening wedge calcaneal osteotomy.

LEVEL OF EVIDENCE

IV, retrospective case series.

Single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata: A case report

Reconstruction of complex soft tissue defects in the distal lower leg remains challenging, since anatomical constraints limit the local options available in this area. In this report, we present a case of single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata. A 55-year-old patient underwent wide excision of a synovial sarcoma in the distal lower leg, which resulted in a complex defect including the peroneus longus and brevis tendons (10 cm), and the overlying skin (14 × 8 cm). Functional reconstruction was achieved in a single stage with a composite anterolateral thigh flap with vascularized fascia lata of similar dimensions to those of the defect. The fascia lata component of the flap was longitudinally split in two segments. Each of them was rolled up, and that way, two separate vascularized neotendons were created. The neotendons bridged the gap of peroneal tendons, whereas the skin paddle of the flap provided stable soft tissue coverage to the reconstructed tendons. Flap pedicle was anastomosed to the anterior tibial vessels. Early and late postoperative periods were uneventful. Follow up at 1 year postoperatively showed excellent neotendon incorporation, as well as a very good functional and aesthetic outcome. The use of the method described may be a useful alternative in single stage functional reconstruction of composite defects comprising two or even more tendons and the overlying skin.

Effectiveness of Allograft Reconstruction vs Tenodesis for Irreparable Peroneus Brevis Tears: A Cadaveric Model

BACKGROUND

Irreparable peroneus brevis tendon tears are uncommon, and there is scant evidence on which to base operative treatment. Options include tendon transfer, segmental resection with tenodesis to the peroneus longus tendon, and allograft reconstruction. However, the relative effectiveness of the latter 2 procedures in restoring peroneus brevis function has not been established.

METHODS

Custom-made strain gage-based tension transducers were implanted into the peroneus longus and brevis tendons near their distal insertions in 10 fresh-frozen cadaver feet. Axial load was applied to the foot, and the peroneal tendons and antagonistic tibialis anterior and posterior tendons were tensioned to 50% and 100% of physiologic load. Distal tendon tension was recorded in this normal condition and after sequential peroneus brevis-to-longus tenodesis and peroneus brevis allograft reconstruction. Measurements were made in 5 foot inversion/eversion and plantarflexion/dorsiflexion positions.

RESULTS

Distal peroneus brevis tendon tension after allograft reconstruction significantly exceeded that measured after tenodesis in all tested loading conditions (P ≤ 0.022). With 50% of physiologic load applied, peroneus brevis tension was 1% to 28% of normal (depending on foot position) after tenodesis and 73% to 101% of normal after allograft reconstruction. Under the 100% loading condition, peroneus brevis tension was 6% to 43% of normal after tenodesis and 88% to 99% of normal after reconstruction with allograft. Distal peroneus longus tension remained within 20% of normal under all operative and loading conditions.

CONCLUSION

Allograft reconstruction of a peroneus brevis tendon tear in this model substantially restored distal tension when the peroneal tendons and their antagonists were loaded to 50% and 100% of physiologic load. Tenodesis to the peroneus longus tendon did not effectively restore peroneus brevis tension under the tested conditions.

CLINICAL RELEVANCE

Because tenodesis was demonstrated to be ineffective for restoration of peroneus brevis function, this procedure may result in an imbalanced foot clinically.

Outcome of Lateral Transfer of the FHL or FDL for Concomitant Peroneal Tendon Tears

BACKGROUND

Concomitant tears of the peroneus longus and brevis tendons are rare injuries, with literature limited to case reports and small patient series. Only 1 recent study directly compared the results of single-stage lateral deep flexor transfer, and no previous series objectively evaluated power and balance following transfer. The purpose of this study was to evaluate clinical outcomes, patient satisfaction, and objective power and balance data following single-stage flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendon transfers for treatment of concomitant peroneus longus and brevis tears.

METHODS

Over an 8-year period (2005-2012), 9 patients underwent lateral transfer of the FHL or FDL tendon for treatment of concomitant peroneus longus and brevis tears. All but 1 patient underwent additional procedures to address hindfoot malalignment or other contributing deformity at the time of surgery. Mean age was 56.9 years, and average body mass index was 27.9. Lateral transfer of the FHL was performed in 5 patients, and FDL transfer performed in 4 with mean follow-up 35.7 months (range: 11-94). Eight of 9 patients completed SF-12 and Foot Function Index (FFI) scores, and 7 returned for range of motion (ROM) and manual strength testing of the involved and normal extremities. These 7 patients also completed force plate balance tests, in addition to peak force and power testing on a PrimusRS machine with a certified physical therapist.

RESULTS

All patients were satisfied with the results of the procedure. Mean SF-12 physical and mental scores were 32 and 55, respectively; mean FFI total score was 56.7. No postoperative infections were noted. Two patients continued to utilize orthotics or braces, and 2 patients reported occasional pain with weightbearing activity. Three patients noted mild paresthesias in the distribution of the sural nerve and 2 demonstrated tibial neuritis. All patients demonstrated 4/5 eversion strength in the involved extremity. Average loss of inversion and eversion ROM were 24.7% and 27.2% of normal, respectively. Mean postoperative eversion peak force and power were decreased greater than 55% relative to the normal extremity. Patients demonstrated nearly 50% increases in both center-of-pressure tracing length and velocity during balance testing. There were no statistically significant differences between the FHL and FDL transfer groups with regards to clinical examination or objective power and balance tests.

CONCLUSION

The FHL and FDL tendons were both successful options for lateral transfer in cases of concomitant peroneus longus and brevis tears. Objective measurements of strength and balance demonstrated significant deficits in the operative extremity, even years following the procedure. These differences, however, did not appear to alter or inhibit patient activity levels or high satisfaction rates with the procedure. Although anatomic studies have demonstrated benefits of FHL transfer over the FDL tendon, further studies with increased patient numbers are needed to determine if these differences are clinically significant.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Rehabilitation after surgical treatment of peroneal tendon tears and ruptures

PURPOSE

The purpose of this study was to provide an overview of the available evidence on rehabilitation programmes after operatively treated patients with peroneal tendon tearsand ruptures.

METHODS

A systematic review was performed, and PubMed and EMBASE were searched for relevant studies. Information regarding the rehabilitation programme after surgical management of peroneal tendon tears and ruptures was extracted from all included studies.

RESULTS

In total, 49 studies were included. No studies were found with the primary purpose to report on rehabilitation of surgically treated peroneal tendon tears or ruptures. The median duration of the total immobilization period after primary repair was 6.0 weeks (range 0-12), 7.0 weeks (range 3.0-13) after tenodesis, 6.3 weeks (range 3.0-13) after grafting, and 8.0 weeks (range 6.0-11) after end-to-end suturing. Forty one percent of the studies that reported on the start of range of motion exercises initiated range of motion within 4 weeks after surgery. No difference was found in duration of immobilization or start of range of motion between different types of surgical treatment options.

CONCLUSION

Appropriate directed rehabilitation appears to be an important factor in the clinical success of surgically treated peroneal tendon tears and ruptures. There seems to be a trend towards shorter immobilization time and early range of motion, although there is no consensus in the literature on best practice recommendations for optimizing rehabilitation after surgical repair of peroneal tendon tears or ruptures. It is important to adjust the rehabilitation protocol to every specific patient for an optimal rehabilitation.

LEVEL OF EVIDENCE

Systematic Review, Level IV.

Use of a Hunter Rod for Staged Reconstruction of Peroneal Tendons

Peroneal tendon pathology is a commonly reported cause of lateral ankle pain. The causes include cavovarus foot type, overuse, chronic tendinosis, peroneal subluxation or dislocation, acute traumatic split tears, and traumatic rupture. The purpose of the present report is to describe an alternative approach for surgical reconstruction of the peroneal tendons in patients when repair might no longer be effective. The use of a Hunter rod was originally described by Hunter in 1971 for 2-stage reconstruction of tendons in the hand. We present a 2-stage surgical technique with the use of a Hunter rod as a temporary implant to stimulate generation of a healthy peroneal tendon sheath to host a flexor hallucis longus tendon transfer. This has proved to be a successful treatment option for patients with severe peroneal tendon damage and scarring along the peroneal tendon sheath. We offer a sample case to illustrate a patient with such indications.

Peroneal Tendon Disorders

Peroneal tendon pathology is often found in patients complaining of lateral ankle pain and instability. Conditions encountered include tendinosis; tendinopathy; tenosynovitis; tears of the peroneus brevis, peroneus longus, and both tendons; subluxation and dislocation; and painful os peroneum syndrome. Injuries can be acute as a result of trauma or present as chronic problems, often in patients with predisposing structural components such as hindfoot varus, lateral ligamentous instability, an enlarged peroneal tubercle, and a symptomatic os peroneum. Treatment begins with nonoperative care, but when surgery is required, reported results and return to sport are in general very good.

Reversal of Peroneal Tenodesis With Allograft Reconstruction of the Peroneus Brevis and Longus: Case Report and Surgical Technique

Chronic peroneal tendinopathy and tears represent a challenging clinical situation. Traditionally, tenodesis of the torn tendon to the remaining healthy tendon has been advocated if more than half of the tendon is compromised. Allograft reconstructions have been reserved for patients with functional muscles and both peroneal tendons extensively compromised. We report a unique case of a peroneal tenodesis takedown and reconstruction of both peroneal tendons using semitendinosus allograft. A description of the surgical technique and tips are provided. Peroneal tendon function is crucial to maintain a balanced hindfoot. To the best of our knowledge, reconstruction of both peroneal tendons after a tenodesis has not been previously reported. Allograft reconstruction of the peroneal tendons arises as a feasible alternative in patients with residual pain and weakness after a failed tenodesis surgery LEVELS OF EVIDENCE: Therapeutic Level IV, case study.

Peroneus longus tears associated with pathology of the os peroneum

BACKGROUND

There is a range of different types of tears and pathology of the peroneal tendons. One of the least common types is the tear of the peroneus longus associated with fracture, enlargement, or entrapment at the cuboid tunnel of the os peroneum. The purpose of this study was to evaluate the pathologic patterns of these uncommon peroneal tendon tears, to review the treatment, and to report the patient outcomes following treatment with excision of the os peroneum, debridement, and tenodesis of the peroneus longus to the peroneus brevis.

METHODS

A 5-year retrospective review of all patients with peroneal tendon tears identified 12 patients operatively treated for peroneus longus tendon tears with associated pathology of the os peroneum, and in whom there was a viable peroneus brevis. All patients were treated with an operative procedure consisting of excision of the os peroneum, debridement, and tenodesis of the peroneus longus to the peroneus brevis. Mean age was 51.5 (range, 33 to 73) years, including 7 males and 5 females. Operative and radiographic records were reviewed to characterize the nature of the peroneus longus tears and associated pathology. Preoperative and postoperative AOFAS hindfoot, SF-36 questionnaires, and Visual Analog Scale (VAS) pain scores were compiled and patient records were reviewed for complications. Mean follow-up after surgery was 63.3 (range, 12 to 114) months.

RESULTS

All of the patients had an os peroneum associated with a complex, irreparable tear of the peroneus longus tendon. The peroneus longus was typically enlarged, fibrotic, and adhered to the surrounding tissues. In 8 patients, the peroneus longus tendon tear was associated with a fracture of the os peroneum, and in 4 patients with an enlarged and entrapped os peroneum which prevented movement at the cuboid tunnel. Of the 12 patients, 9 had partial tears of the peroneus brevis, which were treated with debridement and suture repair. AOFAS hindfoot scores increased from a preoperative mean of 61 (range, 46 to 75) to a postoperative mean of 91.7 (range, 60 to 100). Mean preoperative SF-36 Physical Component Scores (PCS) increased from 36 to 52 postoperatively. Mean VAS pain scores decreased from a preoperative mean of 6.3 (range, 4 to 8) to a postoperative mean of 1.0 (range, 0 to 4). Complications included 2 patients with sural neuritis and 3 with superficial delayed wound healing successfully treated nonoperatively.

CONCLUSION

Tears of the distal peroneus longus tendon, which are much less commonly reported than tears of the peroneus brevis, can be associated with pathology of the os peroneum. Excision of the os peroneum, tendon debridement, and tenodesis of the longus to brevis was an effective surgical technique.

LEVEL OF EVIDENCE

Level IV, case series.

Salvage options for peroneal tendon ruptures

Reports have demonstrated that peroneal tendon tears can be successfully treated by direct repair or debridement and tubularization, based on the extent and nature of the pathology. Irreparable peroneal tendon tears or completely unsalvageable tendons after failure of previously attempted repairs are rare, and as a result there is a lack of high-level evidence to guide the management of these complex injuries. When irreparable tears are encountered the salvage options include tenodesis, bridging of the defect using allografts or autografts, and tendon transfers. The choice of treatment strategy depends on the presence of a functioning tendon or tendons and the viability and excursion of the peroneal musculature.